Unlocking the Power of Non-Claims-Based Payments: Insights that Impact Your Healthcare Organization

Are you really leveraging all available data to optimize your healthcare organization’s performance? It’s possible you’re missing access to insight that’s crucial to the financial health and operational security of your healthcare organization—non-claims-based payments.

Provided by the Centers for Medicare & Medicaid Services (CMS), these payments, which include care coordination, incentive or capitation payments are not tied directly to traditional claims. However, they still represent an essential part of the overall reimbursement structure. These data points are necessary to accurately assess your total spend and financial health. Whether you’re an ACO with minimal non-claim-based payments or participating in programs like CPC+ or Primary Care First, understanding and managing these non-claims-based payments allow you to increase your reliance on data-driven strategies and optimize operations.

What are Non-Claims-Based Payments?

Non-claims-based payments are reimbursements made by the Centers for Medicare & Medicaid Services (CMS), that don’t originate from claims submitted for medical services rendered. These payments serve various purposes in the healthcare system, from incentivizing providers to improving care coordination, to supporting the financial sustainability of value-based care models.

These may include:

• Care Coordination Payments: Compensation for healthcare providers managing patient care across multiple settings, ensuring continuity and quality.
• Incentive Payments: Reward-based incentives for meeting particular performance measures or the achievement of certain health-related outcomes.
• Capitation Payments: Fixed per-patient payments for healthcare services that allow providers to manage patient care within a set budget.

While these payments are not linked to individual claims, they’re often part of larger payment models, such as those seen in ACOs or specific programs like CPC+ and Primary Care First.

Why does access to Non-Claims-Based Payment data matter?

Data is critical to operational efficiency; however, just having data isn’t quite enough. You need data that has context—data that tells a story about your healthcare organization, patients or members, doctors and staff and the overall financial health of your organization. Non-claims-based payments are an additional piece of context to aide in telling the entire story.

Here’s why:

1. Financial Transparency and Reconciliation: Many ACOs may be unfamiliar with these types of payments, as they don’t directly correlate with the claims data they’re used to receiving. Understanding their value and how they influence the final reconciliation package can help organizations better plan and forecast their financial positions. By integrating this data into their financial systems, ACOs can ensure all revenue streams are accounted for, creating comprehensive reporting and ensuring accuracy.
2. Enhancing Data Strategy: Data makes the world go around—and it makes your organization effective. You look to your data strategy to provide the missing pieces to understand how to improve patient outcomes and reduce costs. Non-claims-based payment information, when integrated, completes the view of total revenue for the organization. This view is especially important as many organizations shift to value-based care models, where financial rewards are often tied to quality measures and population health management, rather than the volume of claims processed. Accessing this data allows ACOs to make more informed decisions about care delivery, resource allocation and performance improvement.
3. Optimizing Value-Based Care: Programs like CPC+ and Primary Care First emphasize value-based care, where outcomes matter more than the number of services provided. Non-claims-based payments incentivize providers to meet quality benchmarks and coordinate care more effectively. However, to truly capitalize on these payments, ACOs must understand how they align with their financial and operational goals. By closely tracking these payment types, ACOs can adjust their strategies to maximize the financial benefits while delivering better care to their populations.
4. Mitigating Potential Revenue Gaps: While many ACOs may not see a large impact from non-claims-based payments, organizations that participate in more comprehensive programs may experience a substantial shift in their financial landscape. Incorporating these payments into budgeting and forecasting processes, allow value-based care providers and provider groups to potentially avoid potential revenue shortfalls during the reconciliation process. Accurate tracking of both claims-based and non-claims-based payments ensures healthcare organizations aren’t blindsided by unexpected financial changes.

Integrating Non-Claims-Based Payment Data

The value of this data lies in integrating non-claims-based payment data into a healthcare organization’s overall data strategy.

This requires a multi-step approach:

1. Data Collection and Visibility: To effectively manage non-claims-based payments, organizations must have systems in place to capture and display this data clearly. Tools like Salient Health integrate and provide visibility into these payments, which is crucial for preparing reconciliation packages. Incorporating this data into the organization’s infrastructure helps ACOs better understand their overall financial health.
2. Collaboration Across Teams: Non-claims-based payments impact multiple areas of an organization, from finance to care delivery. Encouraging collaboration between finance teams, care coordinators and clinical teams holds stakeholders accountable to the value and impact of these payments. Regular discussions about how non-claims-based payments are utilized can drive efficiencies in care models and result in improved patient outcomes.
3. Continuous Monitoring and Adjustments: As ACOs engage in more complex programs like CPC and Primary Care First, it’s essential to continually monitor the impact of non-claims-based payments. Regular analysis of these payments allows organizations to adjust care delivery models, optimize resource use and ensure financial incentives associated with value-based care are maximized.
4. Transparency and Stakeholder Communication: Transparency is key. Regular communication with stakeholders about the presence and impact of non-claims-based payments, including any changes, helps maintain alignment across the organization. Providing clear insights into how these payments affect financial outcomes can foster trust and engagement across the care delivery continuum—from physicians to care teams to financial managers.

Conclusion

While non-claims-based payments may not be a major consideration for all ACOs, this data type represents an important element of financial health, particularly for those involved in advanced value-based care programs. By gaining access to this data and integrating non-claims-based payments into their overall data strategy, healthcare organizations can improve financial planning, optimize care delivery and ensure they’re maximizing reimbursement opportunities.

The understanding and visibility into all types of payments, both claims-based and non-claims-based is crucial for organizations striving to succeed in value-based care environments. Proactively incorporating non-claims-based payments into overall strategy can strengthen the financial position of healthcare organizations and improve patient outcomes.